MEDICARE: MRS. JENNIFER MARIE PASSINO MSPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	2305203253	VA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G02052	OTHER	DC	MEDICARE GROUP PIN

General Provider Information

NPI Number	:	1962467480
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENNIFER MARIE PASSINO MSPT

Provider Business Mailing Address
First Line	:	12552 SWEET LEAF TERRACE
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22033-2462
Country	:	US
Telephone Number	:	703-385-3910
Fax Number	:

Provider Business Practice Location Address
First Line	:	10525 WEST DR
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22030-4230
Country	:	US
Telephone Number	:	703-934-9411
Fax Number	:	703-934-9497

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/18/2006
Last Update Date	:	10/05/2007

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